Postpartum hemorrhage.pdf

National Guideline Clearinghouse | Postpartum hemorrhage. Guideline Title Postpartum hemorrhage. Bibliographic Source(s) American College of Obstetricians and Gynecologists (ACOG). Postpartum hemorrhage. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2006 Oct. 10 p. (ACOG practice bulletin; no. 76). [40 references] Guideline Status This is the current release of the guideline. The American College of Obstetricians and Gynecologists (ACOG
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  National Guideline Clearinghouse | Postpartumhemorrhage. /content.aspx Guideline TitlePostpartum hemorrhage.Bibliographic Source(s) American College of Obstetricians and Gynecologists (ACOG). Postpartum hemorrhage.Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2006Oct. 10 p. (ACOG practice bulletin; no. 76). [40 references]Guideline StatusThis is the current release of the guideline.The American College of Obstetricians and Gynecologists (ACOG) reaffirmed the currency of the guideline in 2013.Back to top Scope Disease/Condition(s)Postpartum hemorrhageGuideline CategoryEvaluationManagementTreatmentClinical SpecialtyEmergency MedicineFamily PracticeObstetrics and GynecologyIntended UsersPhysiciansGuideline Objective(s)To aid practitioners in making decisions about appropriate obstetric and gynecologiccareTo review the etiology, evaluation, and management of postpartum hemorrhageTarget Population  Women during the first 24 hours after delivery (at risk for primary postpartumhemorrhage), especially those with:Uterine atonyRetained placenta—especially placenta accretaDefects in coagulationUterine inversionWomen between 24 hours and 6–12 weeks after delivery (at risk for secondarypostpartum hemorrhage),especially those with:Subinvolution of placental siteRetained products of conceptionInfectionInherited coagulation defectsWomen with other risk factors for postpartum hemorrhageInterventions and Practices Considered Evaluation/Management 1. Multi-disciplinary approach with high clinical suspicion2. Laboratory evaluation of lost blood3. Testing for bleeding disorders among patients with menorrhagia4. Medical management, including use of uterotonic agents5. Exploratory laparotomy6. Ultrasonography7. Drainage of hematomas8. Uterine compression or massage9. Tamponade: packing of the uterine cavity, Foley catheter insertion, Sengstaken-Blakemore tube insertion, SOS Bakri tamponade balloon use10. Surgical management, including uterine curettage and hysterectomy11. Arterial ligation or embolization12. Blood component therapy (donor or autologous): packed red cells, platelets, freshfrozen plasma, cryoprecipitate13. Manual replacement of the uterine corpus14. Antibiotics Poststabilization Management 1. Prenatal vitamin and mineral capsules2. Additional iron tablets3. ErythropoietinMajor Outcomes ConsideredTime to cessation of bleedingIncidence of serious sequelae (adult respiratory distress syndrome, coagulopathy,shock, loss of fertility, and pituitary necrosis)  Loss of fertilityMortalityBack to top Methodology Methods Used to Collect/Select the EvidenceHand-searches of Published Literature (Primary Sources)Hand-searches of Published Literature (Secondary Sources)Searches of Electronic DatabasesDescription of Methods Used to Collect/Select the Evidence 2006 Original Document The MEDLINE database, the Cochrane Library, and the American College of Obstetriciansand Gynecologists' own internal resources and documents were used to conduct a literaturesearch to locate relevant articles published between January 1901 and June 2006. Thesearch was restricted to articles published in the English language. Priority was given toarticles reporting results of srcinal research, although review articles and commentaries alsowere consulted. Abstracts of research presented at symposia and scientific conferences werenot considered adequate for inclusion in this document. Guidelines published byorganizations or institutions such as the National Institutes of Health and American College of Obstetricians and Gynecologists were reviewed, and additional studies were located byreviewing bibliographies of identified articles. 2013 Reaffirmation The NCBI database was searched from 2006 to 2013. Committee members conducted aliterature search with the assistance from the ACOG Resource Center staff who routinelyperform the Practice Bulletin literature searches.Number of Source DocumentsNot statedMethods Used to Assess the Quality and Strength of the EvidenceWeighting According to a Rating Scheme (Scheme Given)Rating Scheme for the Strength of the EvidenceStudies were reviewed and evaluated for quality according to the method outlined by the U.S.Preventive Services Task Force: I : Evidence obtained from at least one properly designed randomized controlled trial. II-1 : Evidence obtained from well-designed controlled trials without randomization. II-2 : Evidence obtained from well-designed cohort or case–control analytic studies, preferablyfrom more than one center or research group. II-3 : Evidence obtained from multiple time series with or without the intervention. Dramaticresults in uncontrolled experiments also could be regarded as this type of evidence. III : Opinions of respected authorities, based on clinical experience, descriptive studies, or   reports of expert committees.Methods Used to Analyze the EvidenceSystematic ReviewDescription of the Methods Used to Analyze the EvidenceNot statedMethods Used to Formulate the RecommendationsExpert ConsensusDescription of Methods Used to Formulate the Recommendations 2006 Original Document  Analysis of available evidence was given priority in formulating recommendations. Whenreliable research was not available, expert opinions from obstetrician–gynecologists wereused. See also the Rating Scheme for the Strength of Recommendations field regardingGrade C recommendations. 2013 Reaffirmation The Committee on Practice Bulletins - Obstetrics met in October 2013 and reaffirmed thisdocument. A committee member reviewed the document and new literature on the topic. Thedocument was then reviewed by the committee and the committee agreed that it is currentand accurate.Rating Scheme for the Strength of the RecommendationsBased on the highest level of evidence found in the data, recommendations are provided andgraded according to the following categories: Level A  — Recommendations are based on good and consistent scientific evidence. Level B  — Recommendations are based on limited or inconsistent scientific evidence. Level C  — Recommendations are based primarily on consensus and expert opinion.Cost Analysis A formal cost analysis was not performed and published cost analyses were not reviewed.Method of Guideline ValidationInternal Peer ReviewDescription of Method of Guideline ValidationPractice Bulletins are validated by two internal clinical review panels composed of practicingobstetrician-gynecologists generalists and sub-specialists. The final guidelines are alsoreviewed and approved by the American College of Obstetricians and Gynecologists (ACOG)Executive Board.


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